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Nursing Home Reimbursement

Medicaid Nursing Home fee-for-service rate setting and reimbursement is governed by the authority of Wis. Stat. §. 49.45(6m). The Division of Medicaid Services uses a methodology described in Wisconsin's State Medicaid Plan attachment 4.19-D, the Methods of Implementation for Wisconsin Medicaid Nursing Home Payment Rates (found on the Resources for Skilled Nursing Facilities webpage).

  • Quarterly case mix index (CMI) summary resident rosters for nursing home rates are available through the ForwardHealth Portal.
  • To access your case mix roster, log in to the ForwardHealth Portal and click on “Trade Files,” then “File Download.” The rosters are only accessible to the portal administrator and to those with the portal security role “trade files”.
  • To grant access to a staff member who already has a portal account but does not have the “trade files” security role, have your portal administrator follow the instructions for adding a role, which can be found in section 6.2 of the Provider Portal Account User Guide, P-00952 (PDF).
  • To request provider portal access, complete the Request Portal Access on the ForwardHealth website.
  • Summary rosters are released quarterly and will remain available for download for a period of one year after their release.
  • To request a detailed resident roster showing the CMI of every assessment for each resident and the corresponding number of patient days at each Resource Utilization Groups (RUGs) level, please contact your regional auditor.

Wisconsin Nursing Home Rate Setting (WINHRS) website

Per Wisconsin’s State Plan, nursing homes receiving Wisconsin Medicaid funding are required to submit an independent financial audit to DHS annually.

Resources

The Wisconsin Department of Health Services will host nursing home industry public meetings with a focus on "Wisconsin Medicaid Nursing Facility Payment Method."

Past meetings

DHS updated rates and CMIs described in section 2.42 of the state fiscal year (SFY) 2023 Methods of Implementation for Wisconsin Medicaid Nursing Home Payment Rates (PDF) (found on the Resources for Skilled Nursing Facilities webpage). This aligned them with the CMS parity adjustment (see CMS final rule 1765).

DHS adopted the CMIs published in CMS final rule 1765 effective October 1, 2022.

DHS is updating base rates to the following to offset this CMI change:

Direct care base ratesEffective July 1, 2022Effective October 1, 2022–June 30, 2023
Nursing services base (nursing facilities [NFs] and intermediate care facilities for individuals with intellectual disabilities [ICFs-IID])$122.68$126.31
Other direct care supplies and services base (NF and ICFs-IID)$16.46$16.95
Effective July 1, 2022-September 30, 2022
Rate classificationPatient driven payment model (PDPM) Nursing Payment Group (NPG) Case Mix WeightPDPM Non-Therapy Ancillary (NTA) Case Mix Weight
Non-Developmental Disability (DD) Behold0.320.23
DD2.501.80
DD Bedhold1.380.99
Ventilator5.003.60
Hospice Room and Board (100%)1.451.05
Updates effective October 1, 2022-September 30, 2023
Rate classificationPDPM NPG Case Mix WeightPDPM NTA Case Mix Weight
Non-DD Behold0.310.22
DD2.431.75
DD Bedhold1.340.96
Ventilator4.863.49
Hospice Room and Board (100%)1.411.02
Updates effective October 1, 2023
Rate classificationPDPM NPG Case Mix WeightPDPM NTA Case Mix Weight
Non-DD Behold0.300.21
DD2.361.71
DD Bedhold1.300.94
Ventilator4.733.40
Hospice Room and Board (100%)1.370.99

Glossary

 
Last revised November 27, 2024